Psychosocial determinants associated with success in undergoing peripherally inserted central catheter placement without sedation in pediatric patients

Peripherally inserted central catheters (PICC) are commonly used for prolonged intravenous access in children. Select patients can successfully undergo the short and minimally invasive PICC insertion procedure without sedation. Limiting exposure to sedation is particularly beneficial to patients as members of this population often require many anesthetic events due to medical complexity. We performed a retrospective analysis of patients who successfully underwent PICC line placement without sedation to identify the predictive value of preprocedural screening using the modified Psychosocial Risk Assessment in Pediatrics (PRAP) tool. This retrospective study was approved by Baylor College of Medicine Institutional Review Board (#H42808, 11/6/2018) with consent waived. This study included all patients aged 8–18 years having undergone standard (e.g., uncuffed, nontunneled) PICC placement procedures by interventional radiology without sedation in 2019. Procedures were performed by 9 pediatric interventional radiologists with preoperative assessments performed by child life specialists. The following patient information was collected: height, weight, body mass index, and American Society of Anesthesiology physical status. Psychosocial evaluations were completed in person within prior to procedure (by phone or in person for outpatients and inpatients, respectively) and using a modified PRAP tool with the following psychosocial domains: patient preprocedural anxiety, developmental delay (communication deficit), baseline temperament, and caregiver stress and reported in the child life notes.1 The presence or absence of these factors was recorded with domains observed or assessed by child life. A priori, all domains were weighted equally in the absence of evidence demonstrating unequal distribution with a composite score of these factors calculated as the number of positively identified domains. All of these nonsedation cases were performed solely by the interventional radiology team using local anesthesia with the child life specialist present if requested by the family. Patients having sedation with anesthesiology and those undergoing multiple procedures or bedside PICC procedures were excluded. Categorical variables were described by frequencies and percentages while continuous variables were reported by mean and standard deviation. Our cohort consisted of 178 patients who were identified by child life assessment to be good candidates for a PICC line placement without sedation (Table 1). All patients underwent successful placement by interventional radiology with only local anesthesia as planned after initial psychosocial evaluation with no patients requiring conversion to sedation. The average age of this cohort was 14.6 years. The overall average number of psychosocial factors among these patients was 0.4 factors. None of these patients were noted to have a caregiver with high stress burden. Nonsedate N = 178 This is a single center retrospective descriptive study of a cohort of patients who were prescreened for and successfully underwent PICC line placement without sedation. Bottari et al, report their experience at a United States children's hospital identifying a success rate of 94% for bedside PICC line placement with sedation compared with a success rate of 75% without sedation2; most failures were attributed to patient cooperation and anxiety. There was 100% success rate our cohort who were all identified to be good candidates. In our cohort, 44 (24.7%) patients having successfully undergone PICC placement without sedation were noted to have anxiety on the preprocedural evaluation. The procedural success despite a seemly high prevalence of preprocedural anxiety may be best explained through deliberate preparation by child life providers, which has been proven to reduce anxiety with small procedures (i.e., venipuncture).3 This is likely given that anxiety was the sole positive psychosocial factor noted for 38 (86.4%) of the patients. Thus, preprocedural anxiety may not preclude a child from undergoing a successful procedure, specifically if it is the sole positive factor. Limitations include the retrospective design as well as lack of granular data with regard to psychosocial domains which may benefit from future study, specifically stratification of anxiety. We did not assess if patients underwent previous PICC line placement or other medical interventions although presumably this would be reflected in the anxiety assessment. This study helps to illustrate the importance of psychosocial assessments when making the determination between pharmacologic and behavioral intervention approaches for PICC placement in children. Patients with few to no positive psychosocial assessment domains may be suited to PICC placement without sedation. This is particularly advantageous given the risk of sedation in an often medically complex population. The presence of preprocedural anxiety should not be seen as an absolute contraindication for nonsedation and may be mitigated by deliberate preparation by child life. The authors thank Meghan Schmidt, MS, CCLS and Annie Matlack, CCLS from the Department of Child Life at Texas Children's Hospital for their assistance with this manuscript. None of the authors report any financial disclosures. Ms. Bryant and Dr. Jensen conceptualized and designed the study, collected data, drafted the initial manuscript, and reviewed and revised the manuscript. Drs. Chandrakantan and Dr. Kukreja conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content. Ms. Patel and Ms. Navejar collected data, reviewed and revised the manuscript. Dr Adler: This author conceptualized and designed the study, conducted the statistical analysis, drafted the initial manuscript, and reviewed and revised the manuscript. The data that support the findings of this study are available from the corresponding author upon reasonable request.